Provider Demographics
NPI:1932747243
Name:NYANGANSO, QUEEN
Entity Type:Individual
Prefix:
First Name:QUEEN
Middle Name:
Last Name:NYANGANSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 FERNWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71108-5111
Mailing Address - Country:US
Mailing Address - Phone:318-518-1505
Mailing Address - Fax:
Practice Address - Street 1:2924 KNIGHT ST STE 426
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2414
Practice Address - Country:US
Practice Address - Phone:318-754-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator